Teenagers at risk of unintended pregnancy: identification of practical risk markers for use in general practice from a retrospective analysis of case records in the United Kingdom

The United Kingdom has one of the highest teenage pregnancy rates in Western Europe with a high proportion of unintended pregnancies resulting in termination. General practice is one source of contraceptive and sexual advice for teenagers but it is difficult to target young women most at risk. This study was performed to determine whether it was possible to identify any markers that could alert general practitioners to the need to give appropriate opportunistic preventive advice. This was a retrospective case-control study in which the general practice medical records of young women with a recorded history of termination of pregnancy resulting from conception between the ages of 13-19 years inclusive were examined for details of consultations and contraceptive provision prior to conception. Where appropriate, comparison was made with an age and practice-matched control group. A total of 53 cases were identified and compared with 159 controls. In the 12 months prior to conception approximately half of the cases had discussed contraception and two-fifths had been prescribed oral contraception. A significantly higher proportion of cases than controls had consulted for emergency contraception and also for urinary tract symptoms. Weaker associations were also found with younger age of starting contraception, and also recorded side-effects or dissatisfaction with contraception. Lapsed contraception and previous pregnancy were noted as other potential markers of risk. The findings from this study may assist primary care professionals in focussing opportunistic sexual health interventions at some teenagers who are at higher risk of unintended pregnancy.

Contraceptive counseling in managed care: preventing unintended pregnancy in adults

This study examines contraceptive counseling received by adult women in their managed care plans and the relationship between counseling and women's contraceptive attitudes and practices. Telephone interviews were conducted with a random sample of 898 women ages 18 to 44 enrolled in a commercial health maintenance organization (HMO) or point-of-service (POS) health plan. Counseling received in the past 2 years was measured on three dimensions: exposure through any communication channel; content of information; and personalization of discussion. Multiple logistic regression analysis was used to examine the determinants of counseling and the relationship between counseling and four outcomes: satisfaction with counseling received, self-efficacy for preventing unintended pregnancy, current use of contraception (if at risk of unintended pregnancy), and intent to contracept in the next year (if at risk). Overall, 60.5% of women were at risk of unintended pregnancy; among those at risk, 69% received any counseling in the past 2 years, compared with 38% among those not at risk. Receiving personalized counseling (as opposed to no counseling or only informational counseling) significantly increases the odds of satisfaction with counseling, current contraceptive use, and intent to contracept. Informational counseling alone (without personalization) significantly increases the odds of contraceptive use. Women ages 40-44 were less likely than younger women to receive counseling and to use contraception if at risk of unintended pregnancy. We conclude that receiving contraceptive counseling in managed care is associated with contraceptive attitudes and practices among adults and that there is substantial room for quality improvement in the provision of contraceptive counseling.

Dealing with the risks of unwanted pregnancy and sexually transmitted infections among adolescents: some experiences from Kenya

Studies have suggested the persistence of risky sexual practices among adolescents in Kenya but relatively less is known about the perceptions, norms and gender relations that govern the sexual behaviour of adolescent females and males, or the strategies they use to deal with the twin risks of unwanted pregnancy and STI/HIV infection. This study was, therefore, conducted to explore these issues through data drawn from 16 FGDs among 184 rural male and female adolescents aged 15-19 years in Makueni District of Eastern Kenya. Findings suggest that adolescents are quite aware of risky behaviours and the protective role of abstinence, faithfulness to one uninfected partner and condom use. However, adolescents face a number of obstacles in translating this knowledge into safer sex practices. Misinformation concerning ways to protect themselves abound. Both females and males report reticence in communicating about sexual matters and contraception with their partners. At the same time, they are reluctant to seek condoms in public places for fear of disclosure and reproach. Females face difficulties in negotiating safe sex, in reconciling the desire for condom use with norms demanding submissiveness and lack of assertiveness in contraceptive decision-making. Findings suggest the need for programs that promote communication skills among young male and especially female adolescents, and that seek to change masculine and feminine gender ideologies and redress gender double standards.

Pregnancy planning and acceptance among Danish pregnant women

OBJECTIVE

To study how living conditions influence pregnancy planning and acceptance among Danish women.

METHOD

A cross-sectional questionnaire study performed among 3516 pregnant women attending Odense University Hospital, Denmark. The study population consisted of women with spontaneous abortion, women with ectopic pregnancies, women attending antenatal care and women with induced abortion. They were divided into four groups: women with planned and accepted pregnancies (accepting planners, n=2137), women who accepted an initially unplanned pregnancy (accepting non-planners, n=1006), women who rejected an initially planned pregnancy (rejecting planners, n=31), and women with unplanned and rejected pregnancies (rejecting non-planners, n=342). The association between socio-economic characteristics and pregnancy planning and acceptance was evaluated by comparing accepting non-planners with accepting planners and by comparing rejecting planners with rejecting non-planners. The variables studied comprise age, number of children, partner relationship, education, occupation, economic situation and contraceptives.

RESULTS

The characteristics of accepting non-planners and accepting planners were in accordance and in contrast to those of rejecting planners and in particular of rejecting non-planners. The contraceptive prevalence rate among accepting non-planners was 15%. Among rejecting non-planners the same figure was 51%.

CONCLUSION

Accepting non-planners seemed to be in a situation which could be considered appropriate for childbirth. The contraceptive prevalence rate among accepting non-planners was low and might reflect that these women were not entirely against the thought of having a child, although they did not actively plan to have one.

How contraceptive use patterns differ by pregnancy intention: implications for counseling

To increase awareness of issues to include in contraceptive counseling-the objectives of this study were to evaluate: 1) how contraceptive use patterns (eg, non-use), level of effectiveness of contraceptive method, and sociodemographic characteristics may be associated with the occurrence of unintended pregnancy; 2) patterns of health care use for women with intended and unintended pregnancy; and 3) the association between contraceptive use patterns and sociodemographic characteristics. In-person interviews were conducted with 279 women enrolled in a Medicaid managed care health plan who had been pregnant in the last 5 years. Self-reported measures of pregnancy intention, contraceptive use, and health care use were collected. The relationships of pregnancy intention with contraceptive use patterns, level of effectiveness of contraceptive method used, and patterns of recent health care use were assessed. Differences in contraceptive use patterns by sociodemographic groups were assessed. Seventy-eight percent of women reported an unintended pregnancy. Non-use of birth control the month before conception was reported by 57% of women with unintended pregnancies and 84% of women with intended pregnancies. Use of birth control of low effectiveness was reported by 20% of women with unintended pregnancies and 8% of women with intended pregnancies. Non-use or use of contraceptive methods of low effectiveness did not differ for women in different sociodemographic groups regardless of pregnancy intention status. A majority of women reported recent health care use. Health care providers should be aware that women who have no intention for pregnancy may not be using an effective contraceptive method NOR have an effective pattern of contraceptive use.

Predictors of postpartum depression: an update

BACKGROUND

Approximately 13% of women experience postpartum depression. Early recognition is one of the most difficult challenges with this mood disorder because of how covertly it is suffered.

OBJECTIVES

The purpose of this meta-analysis was to update the findings of an earlier meta-analysis of postpartum depression predictors that had synthesized the results of studies conducted mostly in the 1980s.

METHOD

A meta-analysis of 84 studies published in the decade of the 1990s was conducted to determine the magnitude of the relationships between postpartum depression and various risk factors. Using the software system Advanced Basic Meta-Analysis, effect sizes were calculated three ways: unweighted, weighted by sample size, and weighted by quality index score.

RESULTS

Thirteen significant predictors of postpartum depression were revealed. Ten of the 13 risk factors had moderate effect sizes while three predictors had small effect sizes. The mean effect size indicator ranges for each risk factor were as follows: prenatal depression (.44 to .46), self esteem (.45 to. 47), childcare stress (.45 to .46), prenatal anxiety (.41 to .45), life stress (.38 to .40), social support (.36 to .41), marital relationship (.38 to .39), history of previous depression (.38 to .39), infant temperament (.33 to .34), maternity blues (.25 to .31), marital status (.21 to .35), socioeconomic status (.19 to .22), and unplanned/unwanted pregnancy (.14 to .17).

CONCLUSIONS

Results confirmed findings of an earlier meta-analysis and in addition revealed four new predictors of postpartum depression: self-esteem, marital status, socioeconomic status, and unplanned/unwanted pregnancy.

Adolescent pregnancy 1 year later: the effects of abortion vs. motherhood in Northeast Brazil

PURPOSE

To determine social and behavioral consequences of pregnancy and how these differed according to the pregnancy outcome (live birth or abortion) 1 year after the event.

METHODS

This was a prospective study of two groups of young women aged 12-18 years, one attending prenatal services and the other admitted for abortion complications at the same hospital in northeast Brazil. Adolescents who gave birth were subsequently classified as having intended or unintended pregnancies, and those who aborted were divided between those who terminated their pregnancies and those who miscarried. Baseline data were collected between 1995 and 1997 from all teens who met the eligibility criteria. Information was collected through one-on-one interviews using a questionnaire that was structured and precoded. Multiple logistic regression was used to identify characteristics that predicted outcomes at 1 year.

RESULTS

Teens who terminated their pregnancies were the most likely to be in school or working 1 year later. They also showed the greatest increase in self-esteem. The young mothers, however, had the highest self-esteem but perceived the impact of pregnancy on their lives as being more negative than they did initially. Group affiliation was not associated with the quality of partner relationships, which tended to deteriorate over time. The young mothers used contraception at 1 year at higher rates and had experienced fewer subsequent pregnancies than the two abortion groups.

CONCLUSIONS

The experience of adolescent pregnancy for this group of teens produced mixed findings, some more negative than others. Interventions to decrease the adolescent's desire to have a baby will have to be tailored differently from those designed to prevent an unintended pregnancy, but both are needed.

Consistency between survey and interview data concerning pregnancy wantedness in the Philippines

Through a comparison of survey and in-depth interview data reported by a small sample of Filipino women and men, standard survey questions and the standard conceptualizations of pregnancy wantedness are assessed to determine whether they capture respondents' attitudes toward pregnancies and their timing in two areas in the Philippines. The study reveals that more than two-thirds of respondents were completely consistent in their survey and interview responses. Consistency was higher for women than for men, and it improved when a dichotomous measure (intended/unintended) was used rather than a more detailed variable that distinguished between intended, mistimed, and unwanted pregnancies. To the extent that the two data sources disagree, the interview transcripts suggest two possible reasons for inconsistent reports: deference to a spouse's perceived attitude or the respondent's ambivalence toward or ready acceptance of an unintended pregnancy.

Induced abortions in low socio-economic settlements of Karachi, Pakistan: rates and women's perspectives

OBJECTIVE

The aim of the study was to determine rates on induced abortions and to identify the perceived and actual reasons for terminating an unplanned pregnancy, health care providers sought, methods used and post-abortion complications.

SETTING

Three squatter settlements of Karachi, Pakistan.

SUBJECTS

Interviews were conducted on 1,214 ever-married women in the reproductive age group (15-49) with a reproductive history of at least one pregnancy, irrespective of outcome.

METHODS

A cross-sectional survey from June-August 1997 was conducted in three selected squatter settlements of Karachi.

RESULTS

The abortion rate for the past year was 25.5 per 1,000 women of reproductive age group. The post-abortion complication rate reported was 68.5% (61/89), of which fever and heavy vaginal bleeding was the most commonly reported complication (54.1%).

CONCLUSION

The results indicate that women are aware of the high mortality and morbidity risk resulting from seeking an unsafe abortion but nevertheless opt for this approach to attain their goal of small family size rather than for a modern method of contraception. Furthermore, healthcare providers, irrespective of legality issues, provide such services due to demand. We suggest that family physicians and other relevant health care providers be trained for post-abortion care including post-abortion family planning counseling with an emphasis on emergency contraceptives.

Factors determining the occurrence of unwanted pregnancies

BACKGROUND

We aimed to identify the factors involved in the occurrence of unwanted pregnancy in women seeking medical termination of pregnancy, and to describe their contraceptive practices.

METHODS

A descriptive interview-based study of 402 women seeking abortion was done. Information was gathered regarding demographic variables, contraceptive practices and reasons for the unwanted pregnancy.

RESULTS

All the women in our sample were married and multiparous. The husband's unwillingness for contraception and the improper use of condoms was responsible for one-third of all unwanted pregnancies. Lactation was believed to be a protection against pregnancy by 11.3% of women while 6.3% were unaware of any contraceptive method.

CONCLUSION

We believe that focusing on these areas in public health programmes will help to decrease the number of unwanted pregnancies.

Obstacles to contraceptive use in Pakistan: a study in Punjab

The principal aim of this study is to assess the strength in Pakistan of a set of hypothesized obstacles to practicing contraception. Survey data are analyzed that were collected in Punjab province in 1996 and that contain unusually detailed measurement of various perceived costs of practicing contraception, as well as focused measurement of fertility motivation. The framework guiding the research specifies six major obstacles to contraceptive use: the strength of motivation to avoid pregnancy, awareness and knowledge of contraception, the social and cultural acceptability of contraception, perceptions of the husband's preferences and attitudes, health concerns, and perceived access to services. Net effects of each obstacle are estimated through structural equation modeling of the intention to practice contraception in the near future, in which the six obstacles are treated as latent variables. The estimates indicate that the two principal obstacles to using a contraceptive are the woman's perception that such behavior would conflict with her husband's fertility preferences and his attitudes toward family planning and her perception of the social or cultural unacceptability of contraception. The results confirm the value of taking contraceptive costs seriously, and, in particular, of attempting to measure these costs in empirical research on family planning.

Association between early prenatal care and mother's intention of and desire for the pregnancy

OBJECTIVE

To examine the associations between having planned to become pregnant and valuing an unintended pregnancy with seeking early prenatal care.

DESIGN

This historical cohort study, using data from the National Survey of Family Growth (NSFG), Cycle V (1995), examined separately the associations of having a planned pregnancy (timing of pregnancy) and valuing an unintended pregnancy (feelings about the pregnancy) with timing of initiation of prenatal care.

PARTICIPANTS

The NSFG was based on a national probability sample of women ages 15 to 44 (N= 1,989).

OUTCOME MEASURE

Timing of initiation of prenatal care (early or late/no). Early prenatal care was defined as care sought within the first 13 weeks of pregnancy. It was hypothesized that unwanted and unintended pregnancies were predictors of late or no prenatal care.

RESULTS

In agreement with previous research using logistic regression, unwanted pregnancy was found to be a predictor of late/no prenatal care. Black ethnicity also was found to be a predictor of late/no prenatal care.

CONCLUSIONS

Interventions that are sensitive to culture and involve patient education regarding family planning are needed.

Use of contraceptive methods among homeless women for protection against unwanted pregnancies and sexually transmitted diseases: prior use and willingness to use in the future

Lifetime contraceptive use as reported by a representative sample of 764 homeless women in Los Angeles was examined overall and for different age and ethnic subgroups and contrasted with expressed willingness to use specific methods. Over 80% of the women reported condom use. However, less than 5% had ever used female condoms, although 38% of the overall sample and 73% of the teenagers said they were willing to try them. Similar gaps between reported use and endorsement were found for other particular methods. Native Americans had relatively low use of virtually all contraceptive methods, and over 80% of African-Americans rejected implants. Our findings suggest that age-related factors and ethno-cultural perceptions may deter some homeless women from using contraception. In any case, gaps between realized use and willingness to use may represent missed opportunities to prevent the high rates of unintended pregnancies and sexually transmitted infections found among homeless women.

Perspectives of adolescent boys on the risks of unwanted pregnancy and sexually transmitted infections: Kenya

Sexual debut for boys in Kenya occurs mostly by mid-adolescence. This study looks at the perspectives of adolescent boys aged 15-19 attending schools in rural, eastern Kenya on the dual risks of unwanted pregnancy, STDs and HIV, based on qualitative data from eight focus group discussions with 90 boys. Despite a high knowledge of sexual risks, fear of HIV and awareness of the protective value of condoms, the young men exhibit high risk behaviour. They feel the need to conform to social prescriptions of male prowess, early sexual experience, and having more than one partner, yet their feelings about this behaviour are ambiguous and contradictory. They consider getting girls pregnant and having had a treatable STD as marks of masculinity, blame girls for not protecting themselves (and girls' parents), and want to boast about their sexual conquests to their peers. Yet they feel embarrassed and reticent about discussing sexual issues with adults, and are unwilling to get condoms from places where anonymity is not assured as they know their sexual activity is not sanctioned. There is a clear need for educational programmes that confront male sexual norms, address issues of gender power relations, promote communication skills, informed choice and sexual responsibility among boys as well as girls, and provide a consistent supply of good quality condoms free or at affordable prices.

Short-term grief after an elective abortion

OBJECTIVE

To identify the short-term grief response after elective abortion.

DESIGN

Descriptive, comparative study.

SETTING

Instruments were administered in a women's health clinic.

PARTICIPANTS

Ninety-three women, 45 who had a history of elective abortion within the past 1 to 14 months and 48 who had never had an abortion. Inclusion criteria included no perinatal losses within the past 5 years; no documented psychiatric history; and ability to read, write, and comprehend English.

MAIN OUTCOME MEASURES

Nature and intensity of short-term grief.

RESULTS

Women with a history of elective abortion experienced grief in terms of loss of control, death anxiety, and dependency. Although there were no statistically significant differences in the intensity of grief in women who had a history of elective abortion and the comparison group, there was an overall trend toward higher grief intensities in the abortion group. Presence of living children, perceived pressure to have the abortion, and the number of abortions appear to affect the intensity of the short-term grief response.

CONCLUSION

Elective abortion has the potential for eliciting a short-term grief response. Research is needed to identify which women are at greatest risk. This grief response should be acknowledged and appropriate interventions undertaken.

Pregnancy feelings among adolescents awaiting pregnancy test results

OBJECTIVE

The authors surveyed adolescent girls about their feelings regarding pregnancy.

METHODS

A survey was administered to 117 13- to 18-year-olds who obtained pregnancy tests at nine clinics in Minneapolis and St. Paul, Minnesota, in 1998. The survey included four measures of pregnancy feelings. The authors used bivariate and multivariate logistic regression analyses to examine the associations of these measures with engagement with school, future expectations, social and environmental characteristics, and perceived partner desire for pregnancy.

RESULTS

The four measures of pregnancy feelings were highly correlated (P = 0.0001). Participants reported a range of positive, negative, and ambivalent feelings on all measures. Perceived partner desire for pregnancy, limited future expectations, and lack of school engagement were significantly associated with positive pregnancy feelings for the four measures.

CONCLUSIONS

Successful adolescent pregnancy prevention interventions may include the involvement of partners and key adults as well as strategies to enhance the educational or employment aspirations of girls and adolescents.

The influence of attitudes about unintended pregnancy on use of prenatal and postpartum care

OBJECTIVE

The purpose of this study was to examine the effects of feelings about pregnancy and consideration of abortion on late initiation of prenatal care and postpartum appointment.

STUDY DESIGN

A descriptive study was conducted in a tertiary clinic in Detroit using a convenience sample comprised of 518 low-income pregnant and postpartum women with a large number of unintended pregnancies. A series of chi-square analyses and logistic regression models were conducted to identify variables predictive of these outcomes.

RESULTS

Teenagers were 1.8 times more likely to initiate late prenatal care versus early care (p = 0.05), and women who considered an abortion were 3.7 times more likely to initiate late prenatal care (p = 0.01). Having considered abortion but deciding against it due to psychologic/moral reasons was protective against late initiation of prenatal care (OR = 0.23; p = 0.01). Multiparity was the only predictor of a missed postpartum appointment. Multiparous women were three times more likely to miss the appointment (p = 0.05).

CONCLUSIONS

Success in improving early access to prenatal care will involve addressing the issue of unintended pregnancy. This challenge will require that health care providers assess feelings and values related to a pregnancy. Understanding women's feelings and values about the pregnancy will allow providers to more effectively assist with decision-making and positive pregnancy behaviors. In addition, community-based education related to family planning and the value of prenatal and postpartum care is needed to involve women's partners, family, and friends, because social support systems influence decisions regarding pregnancy behaviors.

Differential risk perceptions for unintended pregnancy, STDs, and HIV/AIDS among urban adolescents: some preliminary findings

Two pilot studies tested the hypothesis that adolescents perceive differential risks for unintended pregnancy (UP), sexually transmitted diseases (STDs), and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). The 1st study used a college sample consisting of 14 adolescents (21 years or younger) and 64 adults (over 21) who rated the likelihood that they and others would experience 15 health problems. The 2nd study used a community sample of 48 adolescents between 16 and 21 years of age who rated 11 health problems in a similar manner. Optimistic bias and uniqueness of risk in adolescents' perceived susceptibility to adverse sexual outcomes were examined. Optimistic bias is the difference between ratings of risk to self and risk to others, reflecting lower risk to self. Uniqueness of risk is the difference between ratings of risk and a baseline risk estimate (i.e., the mean rating for all non-sex-related health problems). Consistent with the hypothesis, adolescents perceived differential risks for UP, STDs, and HIV/AIDS. Implications for adolescent prevention programs are discussed.

Pregnancy intention and pregnancy happiness: are they different?

OBJECTIVES

This study examines the relationship among pregnancy intention and attitudes, inconsistent contraceptive use, and plans for potential pregnancy among 311 women who presented at local health departments to seek a pregnancy test and for whom a pregnancy would be unintended.

METHODS

Women were surveyed prior to receiving pregnancy tests. Pregnancy intention was measured using traditional classifications of mistimed and unwanted pregnancies. Frequency distributions and chi-square tests were computed to examine and compare rates of happiness about the pregnancy among women with mistimed or unwanted pregnancy and to compare rates of inconsistent contraceptive use and plans for the pregnancy by intention and level of happiness.

RESULTS

Although all of the women selected for our sample stated that their pregnancies would be unintended, almost half (46%) were inconsistent contraceptive users. Further, 48% reported that they would be somewhat or very happy about a pregnancy. The proportion of women who were uncertain about the future of a pregnancy and who considered adoption or abortion was highest among those for whom a potential pregnancy was mistimed and who were unhappy about the pregnancy.

CONCLUSIONS

Differentiating between pregnancy intention and happiness has practice implications for family planning and prenatal providers. Additional research should further elaborate these distinctions.

Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity

The relationships between romantic relationship dysfunction and symptoms of borderline personality disorder (BPD), other personality disorders, and depression were examined prospectively in a community sample of 142 late adolescent women. Although BPD symptoms predicted 4-year romantic dysfunction (romantic chronic stress, conflicts, partner satisfaction, abuse, and unwanted pregnancy), the associations were not unique to BPD. Instead, relationship dysfunction was better predicted by a cumulative index of non-BPD Axis II pathology. Depression did not predict outcomes uniquely when Axis II symptoms were included, except in the case of unplanned pregnancy. The results suggest that although BPD is associated with relationship dysfunction, the effect is a more general phenomenon applying rather broadly to Axis II pathology. The results also highlight the importance of subclinical psychopathology in the construction of early intimate relationships.

Partner support and pregnancy wantedness

BACKGROUND

Women who experience unwanted pregnancy are at a greater risk of complicated pregnancy outcomes, and their children are more likely to experience physical or psychological problems in infancy, than those women with wanted pregnancies. The objective of this research was to explain the impact of a partner on women's decisions to want or not want their pregnancies.

METHODS

A primary study subsample of 349 clinical interviews of pregnant women comprised the quantitative portion of the analysis, with a secondary study subsample of 20 in-depth qualitative interviews of pregnant women complementing the statistical findings. Both samples included adult women (at least age 20 yr) of different ethnic groups who received Medicaid for their pregnancies and were in their first or early second trimester of pregnancy. Chi-square, t tests, and logistic regression were used for statistical analyses.

RESULTS

A partner's stability, status, feelings toward pregnancy, and level of dependability and support all had a significant influence on women's experiences of unwanted pregnancy. Variables including use of contraception (OR = 3.3), women's ethnicity (OR = 1.9), partner's feelings about pregnancy (OR = 2.0), amount of social support (OR = 1.2), and mother's instrumental support (OR = 0.85) all affected women's perceptions of wanting the pregnancy. These results were used to create a model of unwanted pregnancy, beginning before conception and ending with either termination of pregnancy or initiation of prenatal care.

CONCLUSIONS

The support and concern of a partner during pregnancy can have positive consequences for a mother's desire to carry out the pregnancy. To increase their commitment to the pregnancy and childbirth, partners should be included more in the prenatal care process.

Factors affecting contraceptive use in women seeking pregnancy tests: Missouri, 1997

CONTEXT

If the national health objective of reducing unintended pregnancy is to be met, a better understanding is needed of barriers to women's acquisition and use of contraceptives.

METHODS

A sample of 311 Missouri women who were seeking pregnancy tests in public health department clinics in 1997 and who said their potential pregnancy was unintended were asked about potential barriers to family planning. Factors affecting contraceptive use among these women were examined by frequency of use, insurance status, education and race.

RESULTS

In general, the women mostly disagreed that particular factors were potential barriers to contraceptive use. For only one item--worry over the potential side effects of the hormonal injectable contraceptive--did a majority agree or strongly agree that it was a barrier to method use in the previous six months. Women who used a contraceptive infrequently were more likely than frequent users to identify 33 factors in nine areas as being potential barriers to contraceptive use. These ranged from factors involving access to services and condom-specific issues to cost-related concerns, social norms, pregnancy denial, embarrassment over discussing or obtaining birth control, worry about side effects and experience with forced sex, among others. Perceived barriers differed somewhat by insurance status in the areas of access, embarrassment, side effects and forced sex. For example, women with no insurance coverage reported a higher level of agreement that transportation problems had hindered their access to a clinic than did women with private insurance. Level of education affected agreement only in the area of side effects, with more-educated women expressing greater concern about side effects than less-educated women. The respondent's race affected agreement in six areas: access, social norms, pregnancy denial, embarrassment, forced sex and other miscellaneous concerns, such as condom use and relationship issues.

CONCLUSION

Better education and improved access to and delivery of services might address several factors affecting contraceptive use that are associated with unintended pregnancy. Some barriers, however, such as those related to self-efficacy, self-esteem and fatalistic attitudes about pregnancy, would be much harder for family planning providers to resolve.

ACOG educational bulletin. Psychosocial risk factors: perinatal screening and intervention. Number 255, November 1999. American College of Obstetricians and Gynecologists

Addressing the broad range of psychosocial issues with which pregnant women are confronted is an essential step toward improving women s health and birth outcomes. This may be difficult to do completely in a private physician s office setting, therefore, an effective system of referrals is helpful. To increase the likelihood of successful interventions, psychosocial screening should be performed on a regular basis and documented in the patient s prenatal record.

The process of decision-making on abortion: a grounded theory study of young men in Sweden

PURPOSE

To gain knowledge of the attitudes, questions, and problems in decision making on abortion by young men recently informed about the positive pregnancy tests of their girlfriends. This knowledge will be used as a basis for developing a service for such young men.

METHODS

A grounded theory approach was used for interviews at an outpatient clinic for adolescents in Sweden with 18 individuals faced with sharing the decision about abortion.

RESULTS

In a suggested model, the decision-making process can be understood by three concepts: reactions (including feelings, apprehensions, and moral conflicts), impact factors (including quality of relationship, consideration for girlfriend, and psychosocial factors), and tools for process (including communication, secrecy/confidentiality, and organized support).

CONCLUSIONS

This study suggests the importance of helping the male adolescent with his reactions as a condition for using the equipment constituting impact factors and tools for process on the way to decision about abortion.

Providing health care to human beings trapped in the poverty culture

The culture of poverty impacts everything patients in this socioeconomic group think and do. If what poor patients say does not sit well with the way we think, that doesn't mean they are wrong. Physicians have to adjust their mental model and think in different cultural terms. The author recently completed his thirtieth year of a career dedicated to providing health care to people living in poverty. He shares seven concepts important in building a mental model that will enable physicians to successfully provide health care to this patient population: (1) Poverty is the number one health problem; (2) we see same diseases as everyone else; (3) patients are trapped in the poverty culture; (4) patients' behavior is often manipulative; (5) compliance is a unique challenge; (6) patients have limited resources; and (7) the ultimate contributors to poverty are unwanted adolescent pregnancy and substance abuse. These concepts can help physicians to be more effective in providing health care to patients living in poverty. They can help them understand what is happening, so that their experience might be fulfilling rather than demoralizing.

[Multiple voluntary abortions]

Repetitive abortions reveal an ambivalence towards contraception. The desire for pregnancy does not always go along with a desire for motherhood. It is a neurotic expression full of guilt that shows that these women did not overcome a childish rivality with their mothers, and remain within a symbiotic relationship with them.

Interaction effects of emotional status and sexual abuse on adult sexuality

This study examined the additive, interaction effects of emotional status with sexual abuse on adult sexual functioning and sexual responsibility. The Golombok Rust Inventory of Sexual Satisfaction (GRISS; Rust & Golombok, 1986), the Personality Assessment Inventory (PAI; Morey, 1991), and a questionnaire regarding sexual experiences, number of unwanted pregnancies, number of unsafe sexual partners, and sexual abuse history, were administered to 200 psychology students. One hundred and forty-three participants were retained in the study. Two-way multivariate analyses of variance (MANOVA) were conducted for the sexual functioning variables (as measured by the GRISS), while two-way analyses of variance (ANOVA) were conducted for the sexual irresponsibility variables (as measured by the sexual experiences questionnaire). It was found that women who have high anxiety scores on the PAI and have a history of sexual abuse reported higher numbers of unwanted pregnancies, while sexual abuse history was not associated with numbers of unwanted pregnancies for women with lower levels of anxiety. Results were not significant, however, for the sexual functioning variables. In addition, depression and alcoholism did not have interacting effect on the association between sexual abuse history and any of the sexuality variables. These results may suggest that the effects of sexual abuse on adult sexuality may not be as pervasive as was once thought.

Partner effects on a woman's intention to conceive: 'not with this partner'

CONTEXT

Current definitions of pregnancy intention that are useful at aggregate levels are weak at the individual level. This is especially true in social contexts where childbearing and pregnancy often occur within casual or transient relationships.

METHODS

Extensive data on lifetime partnerships and sexual behaviors, including pregnancies and births, from 250 low-income women who had experienced a total of 839 pregnancies are used to explore correlates of intention to conceive, as well as the extent to which women attribute their intentions to a current partnership.

RESULTS

Some 57% of reported pregnancies were unintended. Overall, 21% of the women had not wished to conceive at least one of their pregnancies with the partner who impregnated them; that proportion rose to 33% among women who had had only unintended pregnancies. Even among women who had had no unintended pregnancies, 18% had had at least one conception that they had not wanted with their partner at the time of conception. Women were less likely to say they had not wanted to conceive with a particular partner if they were living with that partner than if they were not. The likelihood of not having wanted a pregnancy with a given partner rose with the lifetime number of serious partners. Pregnancies that were not wanted with a particular partner were more than twice as likely to end in abortion as were those that were (33% vs. 14%).

CONCLUSIONS

Among these women, the desire to avoid childbearing relates more to the couple involved in the conception than to abstract notions of completed family size. It would therefore be useful to include items pertaining to partner relationships in future studies of pregnancy intention.

Pregnancy wantedness in adolescents presenting for pregnancy testing

PURPOSE

To explore and describe dimensions of pregnancy wantedness in adolescents who present for pregnancy testing.

DESIGN

Descriptive survey.

METHODS

Adolescents presenting for pregnancy testing at a multiservice teen center were invited to participate by completing the Pregnancy Importance Questionnaire while awaiting the results of their pregnancy test. Eighty-nine adolescents responded to questions concerning their desire for pregnancy, knowledge and access to birth control information and supplies, and expectations of how a pregnancy would change their lives.

RESULTS

Approximately 7% wanted the pregnancy test to be positive, 60% wanted it to be negative, and 33% were not sure. There was a moderately low (1.97 out of 5) desire for pregnancy, a moderately high (3.11 out of 5) knowledge of and access to birth control, and moderately low (2.08 out of 5) expected changes with a pregnancy. There were no differences in these dimensions by age group (early, middle, and late adolescence).

CLINICAL IMPLICATIONS

All clinicians working with adolescents should explore sexual risk-taking and pregnancy prevention measures among these clients. Appropriate counseling and follow-up is necessary for adolescents who present for pregnancy testing, whether the pregnancy test is positive or negative.

Abortion: behaviour of adolescents in two districts in Kenya

BACKGROUND

In Kenya the reported high rates of unwanted pregnancies (more than 90%), among adolescents have subsequently resulted in unsafely induced abortions with the associated high morbidity and mortality rates.

OBJECTIVE

To evaluate the adolescents' behaviour regarding induced abortion.

DESIGN

A cross-sectional, prospective study done from July 1995 to June 1996.

SETTING

Schools and health facilities in Kiambu and Nairobi districts in Kenya.

PARTICIPANTS

Interviews were conducted among adolescents aged 10-19 years in schools at the two districts and selected using a multi-stage random sampling procedure, as well as adolescent girls at two hospitals and two clinics in the immediate post-abortion period.

MAIN OUTCOME MEASURES

The number of adolescents health programmes, aimed at reducing the dangers of unsafely induced abortion, which are designed and subsequently implemented.

DATA COLLECTION

Demographic and health data, as well as data on behaviour regarding induced abortion were collected using a self-administered questionnaire.

RESULTS

The study sample comprised 1820 adolescents. These were 1048 school girls (SG), 580 school boys (SB) and 192 post-abortion (PA). Many adolescents were aware of abortion dangers, with the awareness being significantly lower among the SB whose girlfriends (GF) had aborted than those whose GF had not (p < 0.01). The practice of abortion was reported among 3.4% SG, 9.3% SBs' GF and 100% PA. Direct and indirect costs of abortion were heavy on the girls. Knowledge of the abortion dangers had no influence on the choice of the abortionist. Abortion encounter positively influenced approval by the adolescents, of abortion for pregnant school girls (p < 0.01).

CONCLUSION

Despite the costs and awareness of abortion dangers by adolescents, they will take risks.

Avoiding unwanted pregnancy--the role of communication, information and knowledge in the use of contraception among young Norwegian women

Despite relatively easy access to contraceptives, a liberal attitude to pregnancies out of wedlock and a widespread family planning education in schools, too a high number of adolescent women in Oslo, the capital of Norway, become pregnant and resort to abortions. The aim of this study was to identify some new entry points to sexuality, contraceptive, abortion and post-abortion counselling. Using a qualitative approach, we interviewed 102 young women in Oslo who were seeking either an abortion or contraceptives. The study demonstrated that contraceptive awareness is good, but that there are different levels of consistency in contraceptive use among women, and that even women with few partners and fairly good contraceptive compliance sometimes experience unplanned pregnancy. The study reviews some issues of importance where communication with young women could be improved. These issues include better formal information about OCs, increased information on emergency contraception, better condom promotion, and an attempt to involve better informed adults, including paramedical professional counselling. In addition, contraceptive prescriptions should accord to the type of behaviour and the relationships the young women have.

Compliance and other issues in contraception

About 5% of women in the United States (approximately three million) are not using contraception despite being at risk of unintended pregnancy. Teenagers have the highest rate of unintended pregnancy. Women 40 years and older most frequently terminate unintended pregnancy. Multiple theories and models, including the health belief model, the health decision model, the Prochaska change model, and the conviction-confidence model, have been developed to address choices and change in health behavior. Despite this information, current data on contraceptive compliance show considerable need for improvement. Side effects and patients' beliefs and preferences appear to influence strongly whether a method will be used appropriately. Systems improvements that address issues such as access and enhancement of provider-patient interaction appear to be areas of potential opportunity. Despite continued need for improvement, there is a paucity of information testing new approaches to improve contraceptive compliance.

Adolescents' pregnancy intentions: relations to life situations and caretaking behaviors prenatally and 2 years postpartum

PURPOSE

This study explores if and how adolescents' pregnancy intentions relate to life situations and health-related behaviors prenatally and up to 2 years postpartum.

METHODS

Adolescent girls who reported that they had "wanted a baby" (n = 75) as their reason for pregnancy were compared with those who reported that the pregnancy "just happened" (n = 79) at four separate time periods: prenatally, at 6 and 24 months postpartum, and at 18 months postpartum for teens who became pregnant again subsequent to the study pregnancy.

RESULTS

Those who stated that they wanted a baby were more likely to be Hispanic, married, and out of school before becoming pregnant. They were less likely to receive welfare as their primary means of support and to have run away from home in the past than teens who stated that their pregnancy just happened. Self-reported reason for pregnancy was unrelated to repeat pregnancy by 18 months postpartum, but those who had wanted the study baby were less likely to undergo elective termination of a subsequent pregnancy and less likely to become pregnant by a different partner. The groups diverged at 24 months postpartum when those who wanted a baby were more likely to be married to the father of the baby, be financially supported by him, receive child care assistance from him, and have attempted or succeeded at breastfeeding the study child.

CONCLUSION

Self-reported reason for pregnancy reveals many important characteristics of pregnant adolescents both at the time of presentation and up to 2 years postpartum. Young women in this study who reported intentional pregnancy seem to fare better with regard to their financial status and their relationship with the father of the baby.

A prospective study on quality of life and traumatic events in early life--a 30-year follow-up

AIM

To investigate the connection between early life trauma and the quality of life some 30 years later in Denmark.

DESIGN

Prospective, longitudinal study with questionnaire-based follow-up survey.

METHODS

In 'The Quality of Life Research Study of 10,000 Danes', a newly designed questionnaire was mailed in February 1993 to 7222 persons from the Prospective Paediatric Cohort of persons born at the State University Hospital in Copenhagen (Rigshospitalet) between 1959 and 1961. Response rate was 64% (4626 people between the ages 31-33).

VARIABLES

Mother's attitude towards her pregnancy, child being placed in a children's home, mother using antipsychotic drugs indicating acute, mental illness, child adopted in the first year of life and quality of life of the child 31-33 years later.

RESULTS

Of the early life traumas studied, only relatively weak connections to the quality of life in later life were found.

CONCLUSIONS

These relatively weak findings suggest that the children that survive to adulthood are resilient to many adverse events in early life.

Timing of suicide attempts by self-poisoning during pregnancy and pregnancy outcomes

OBJECTIVE

The purpose of this study was to examine the timing and consequences of suicide attempts by self-poisoning during pregnancy.

METHODS

A population-based prospective study was organised in the toxicological in-patient hospital in Budapest which is responsible for health services for adult inhabitants poisoned by ingesting chemicals in Budapest and the surrounding area involving 3 million people between 1985 and 1993. All women aged between 16 and 50 years (22969) who were admitted to the study hospital due to suicide attempts by drug ingestion were examined by a sensitive serum pregnancy test.

RESULTS

Of 559 self-poisoned pregnant women, two died. The peak period of suicide attempts was found to be in the first postconceptual month and its majority resulted in a very early fetal loss. The second highest figure was recorded in the second postconceptual month. Thus, 61% of suicide attempts occurred before the third postconceptual month. Later pregnancies had a significantly lower proportion of attempting suicide parallel with advanced fetal development.

CONCLUSIONS

Most suicide attempts by self-poisoning occurred after the early recognition of unwanted pregnancies and most resulted in a very early fetal loss. Pregnancies with advanced gestation months had a significantly lower proportion of attempting suicide.

Repeat abortion: a qualitative study

In a qualitative study of 20 women seeking a repeat abortion, interviews lasting for 1.5-2 hours were conducted after the first appointment with a gynecologist when the abortion was planned. The women were aged 20-29 years and had experienced one to five abortion(s) during the previous 5 years. The aim of the study was to attain understanding of the phenomenon of repeat abortion. The women were asked to express their thoughts related to their situation and their choices. The following categories were found: psychosocial background factors, reactions to previous abortion(s), reflections on fertility, sexuality, psychological factors, social factors, contraceptive use, the present pregnancy, motives for the planned abortion, feelings about the planned abortion and risk-taking process. Most of the women seemed to have a psychological vulnerability with many current and previous problems, as well as problems regarding sexuality. It was evident that insecurity was present in the use of contraceptives and in relation to sexual activities and to sexual partners. The main reason for an unplanned pregnancy is not a lack of information or even a lack of knowledge, but rather a failure to integrate the knowledge with situational, intrapsychic and social factors.

Exploring the concepts of intended, planned, and wanted pregnancy

BACKGROUND

A variety of terms have been used to define the intention status of pregnancies. The purpose of this study was to explore how women relate to these terms and how they define the intention status of their pregnancies. Improved understanding of how women use these terms may enhance communication between physicians, patients, and families.

METHODS

This qualitative study used in-depth semistructured interviews to explore how women defined the intention status of current, past, and hypothetical pregnancies. Eighteen women who were seeking prenatal care, elective abortion, or pregnancy testing were interviewed. Most of the subjects were interviewed in the first trimester of a current pregnancy. Four researchers independently reviewed the interview transcripts and summarized the points made by each subject.

RESULTS

Three major themes emerged from the interviews: (1) definitions of terms related to pregnancy varied substantially among women and seemed to be highly correlated to social and cultural influences; (2) the concepts of wanted and unwanted pregnancy were qualitatively distinct from the concepts of planned and unplanned pregnancies and seemed to be more relevant to the decision to continue or abort the pregnancy; and (3) attitudes of the male partners toward the pregnancies were very influential in how women defined their pregnancies.

CONCLUSIONS

Physicians should explore the attitudes and circumstances of pregnant women, rather than focusing on whether the pregnancy was planned. Support from the significant other and the woman's underlying values about parenthood seem to be of particular importance. Our results also suggest that further studies are needed to determine the best method for measuring the intention status of pregnancy for research and policy.

Abortion, intimacy, and the duty to gestate

In this article, I urge that mainstream discussions of abortion are dissatisfying in large part because they proceed in polite abstraction from the distinctive circumstances and meanings of gestation. Such discussions, in fact, apply to abortion conceptual tools that were designed on the premiss that people are physically demarcated, even as gestation is marked by a thorough-going intertwinement. We cannot fully appreciate what is normatively at stake with legally forcing continued gestation, or again how to discuss moral responsibilities to continue gestating, until we appreciate in their own terms the goods and evils distinctive of gestational connection. To underscore the need to explore further the meanings of gestation, I provide two examples of the difference it might make to legal and moral discussions of abortion if we appreciate more fully that gestation is an intimacy.